Authorization for Release of Information Authorization for Release of Information All Clients Client InformationToday's Date(Required) Month Day Year Name(Required) First Name(Required) Last Date of Birth(Required) Month Day Year Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Release of InformationRelease Information to(Required) Health Care Provider/Doctor Insurance Company School/Daycare Other Providers All of the Above - to effectively communicate with all providers Collect Information from(Required) Health Care Provider/Doctor Insurance Company School/Daycare Other Providers All of the Above - to effectively communicate with all providers Discuss Information with(Required) Health Care Provider/Doctor Insurance Company School/Daycare Other Providers All of the Above - to effectively communicate with all providers This Release of Information is reguarding(Required) Therapy (ST, OT, PT) Developmental Disabilities IEP/IFSP Other All of the Above - to effectively communicate with all providers Name of Health Care Provider/Doctor(Required) Insurance Company(Required) School/Daycare(Required) Other Providers/Therapist/Counselor(Required) Your Rights with Respect to this Authorization Right to inspect or copy the health information to be used or disclosed – I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this release form. Right to receive a copy of this release–I understand that if I agree to sign this authorization, which I am not required to do, I will be provided with a signed copy of this form upon request. Right to withdraw this authorization–I understand written notification is necessary to cancel this authorization. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the entity(s) listed above have already made in reference to this authorization. Right to refuse to sign this authorization–I understand that I am under no obligation to sign this form and that the entity(s) listed above may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits based on my decision to sign this authorization Expiration date–This authorization is good for 1 year from the dated signed. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes. By signing this form, I hereby authorize ST CROIX THERAPY, INC. (742 Sterbenz Dr Hudson, WI 54016) to Obtain and/or Release information to the entities/person(s) listed.Responsible Party Information (Client or Parent/Guardian)Name(Required) First Name(Required) Last Phone(Required)Email(Required) Consent to email all reports/records to the email address listed above.(Required) I agree